Manager Patient Safety & Accreditation

Regular Full-Time


901 West Main Street, Freehold, NJ

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CentraState Medical Center

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This position is a dual role encompassing Patient Safety and Accreditation/Regulatory Compliance programs. Requires a highly trained clinical professional, with demonstrated passion for patient safety who will function as the patient safety advocate and mentor, interfacing with staff, leadership and patients.  The Accreditation and Patient Safety Manager will be expected to collaborate and provide leadership to staff members’ daily efforts for identify and remove barriers for safe patient care delivery.  The primary role of the Accreditation and Patient Safety Manager is to foster a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce errors and improve patient outcome. This position supports the activities and projects approved Administrative Leadership and approved by the Patient Safety Committee. This position reports directly to the Vice President Quality and Patient Safety.


  • Manages the facility Patient Safety Program including Patient Safety Plan and TJC requirements for the collection, analysis and reporting of events and patient safety data, investigation of events and near misses, and ensuring all accreditation and regulatory requirements for patient safety are fully met.
  • Facilitates initiatives and programs to mitigate identified risks which result in reduced costs, reduced adverse patient outcomes and safer patient care.
  • Create systems and processes to continually evaluate safety information. Monitor established safety results and compile and present reports to administrative leadership with executive summaries and recommendations for actions as needed.
  • Facilitates teams as necessary to achieve performance improvement and high reliability within the organization.
  • Educates staff in continuous quality improvement and patient safety concepts, processes, and tools as needed.
  • Manages the collection, measurement and presentation of data required for monitoring plans of correction, Joint Commission National Patient Safety Goals (NPSG), and patient safety indicators.
  • Leads the hospital accreditation survey process. Reviews accreditation and regulatory agencies survey findings and develops and manages action plans to address non-compliance.
  • Performs ongoing reviews of regulations for state, federal and other regulatory agencies, and apprises management of changes.
  • Leads the team in any Root Cause Analysis and Failure Mode Effect Analysis necessary, documents and report finding to the appropriate leaders, committees or external agencies.
  • Provide ongoing report to the Patient Safety Committee on all open plans of correction items.
  • Prepares directives, guidelines, information on various topics of patient safety and ongoing compliance for dissemination throughout the Organization.

  • Bachelor’s Degree Required
  • Master’s Degree Preferred
  • RN preferred
  • Certification CPPS, CPHRM, CPHQ preferred
  • 5 years’ experience accreditation or 3-5 years’ experience in patient safety or risk management
About Us

CentraState Healthcare System, a partner of Atlantic Health System, is a fully accredited, not-for-profit, community-based health system that provides comprehensive health services in the central New Jersey region. In addition to offering a full range of leading-edge diagnostic and treatment options, CentraState serves as a valuable health partner focused on the latest ways to prevent disease, promote healthy behaviors, and help people of all ages live life well. Based in Freehold, CentraState is comprised of a 284-bed acute-care hospital, a vibrant health and wellness campus, three award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions offering primary care and specialty physician practices, along with access to outpatient services, such as lab and physical therapy. The system also offers a family medicine residency and geriatric fellowship training program in affiliation with Rutgers Robert Wood Johnson Medical School. Among its many honors and accreditations, CentraState is one of less than two percent of hospitals nationwide to earn Magnet® designation for nursing excellence four times and was designated a Great Place to Work-Certified™ Company by Great Place to Work® for the second consecutive year.


When you bring your talent to CentraState, you are joining a trailblazing healthcare facility, committed to providing high-quality, patient-focused care. Join us in making incredible strides in health care, and making a difference in our community. We believe in enriching the lives of our employees through work/life balance initiatives, tuition assistance, career advancement opportunities and much more.


Find out why our employees love their jobs and being part of the CentraState family!


What We Offer:

  • Highly competitive compensation
  • Excellent benefits package and rewards program
  • 403(b) retirement plan with company match
  • 401(a) retirement plan with employer contribution
  • Life Insurance 
  • Tuition Reimbursement Program
  • Profit Sharing Program
  • Growth Opportunity and Workforce Development Initiatives
  • Continuing Education / Onsite Training
  • A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
  • Concierge Services with Work & Family Benefits
  • Magnet recognized healthcare facility
Commitment to Diversity and Inclusion

At CentraState Healthcare System, we welcome and promote the diversity of our employee family!  Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.


CentraState Healthcare System, is an equal employment opportunity employer and federal contractor or subcontractor and, therefore, abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, gender identity or expression, sexual or affectional orientation, national origin or nationality, citizenship status, disability, age, genetics, protected veteran status, ancestry, marital status.